DSM-5 UPDATE TO THE FAMILY PHYSICIAN S PSYCHIATRIC REVIEW OF SYMPTOMS DANIEL KUCKEL, MD, MS, MBA

Transcription

1 DSM-5 UPDATE TO THE FAMILY PHYSICIAN S PSYCHIATRIC REVIEW OF SYMPTOMS DANIEL KUCKEL, MD, MS, MBA

2 OVERVIEW AND OBJECTIVES DEVELOP A NEW PSYCHIATRIC REVIEW OF SYMPTOMS Based on DSM-5 Criteria New understanding of the family physician s role 2

3 BACKGROUND WHY THIS TOPIC? 1998 ARTICLE CHANGES IN DSM CHANGES IN FAMILY MEDICINE CHANGES IN MILITARY MEDICINE

4 1998 DSM-4 MNEMONICS INTERVIEW TECHNIQUES Normalization Symptom Assumption

5 DSM ANOTHER WAY TO ORGANIZE? INTERVIEW TECHNIQUES Normalization Symptom Assumption

6 FAMILY PHYSICIAN S PSYCHIATRIC REVIEW OF SYMPTOMS 1998 DSM DSM-5 Why important? 25-30% PCM visits Increased diagnosis and therapy Review of Symptoms Mnemonic Don t Miss H&P Conditions Covered Depression Personality Disorder Substance Abuse Anxiety Somatization Cognitive Disorder Psychotic Disorder All of these + ADHD Adjustment Disorder PTSD Autism Spectrum Disorder (- Somatization) 6

7 DSM-5 CHANGES IN ORGANIZATION OF MATERIAL No more Axis I, II, III, IV, V (GAF) 20 disorder chapters in developmental sequence MORE FEASIBLE AND CLINICALLY USEFUL NOT WITHOUT CONTROVERSY

8 THE BIG THREE IN FAMILY MEDICINE ANXIETY DEPRESSION ADHD

9 ANXIETY ROS Excessive worry? DSM5 Anxiety Disorders Panic Disorder and Agoraphobia unlinked Obsessive Compulsive and Related Disorders

10 ROS DEPRESSION Feeling depressed or little interest in activities? DSM5 Depressive Disorders

11 ADJUSTMENT DISORDER NOT MENTIONED IN 1998 INCORPORATES BOTH ANXIETY AND DEPRESSION DSM5 Trauma and Stressor-related disorders

12 ROS ADHD Difficulty sustaining attention or always on the go? DSM5 Neurodevelopmental Disorders

13 ANOTHER WAY TO ORGANIZE THE ROS DON T MISS HISTORY AND PHYSICAL A NEW SCREENING TOOL

14 HISTORY AND PHYSICAL Subjective CC: HPI: ROS: Soc Hx: Objective BMI: A&OX3: MSE: Skin:

15 HISTORY AND PHYSICAL Subjective CC: Difficulty sleeping/concentrating HPI: Panic attack/sigecaps ROS: SI/HI/AVH Soc Hx: Alcohol/Tobacco/Drugs Objective BMI: <19 A&OX3: Disoriented MSE: appearance, grooming Skin: Evidence of cutting Russell s sign

16 HISTORY AND PHYSICAL Subjective DSM-5 CC: Difficulty sleeping/concentrating Review of Symptoms: - GAD-2/Excessive worry? - PHQ-2, PHQ-9 - Difficulty completing tasks? - MCHAT?

17 HISTORY AND PHYSICAL Subjective DSM-5 CC: Difficulty sleeping/concentrating Review of Symptoms: - GAD-2/Excessive worry? - PHQ-2, PHQ-9 - Difficulty completing tasks? - MCHAT? Adjustment Disorder/GAD Adjustment Disorder/MDD ADHD Autism Spectrum Disorder

18 HISTORY AND PHYSICAL Subjective DSM-5 ROS: SI/HI Manic (sleepless, hyperproductive) Traumatic Event? Injury to self/relationships? AVH/Anyone harassing you?

19 HISTORY AND PHYSICAL Subjective DSM-5 ROS: SI/HI Manic (sleepless, hyperproductive) Traumatic Event? Injury to self/relationships? AVH/Anyone harassing you? Bipolar Schizophrenia Borderline PD PTSD

20 HISTORY AND PHYSICAL Subjective DSM-5 Soc Hx: Alcohol/Tobacco/Drugs Review of Symptoms: CAGE

21 HISTORY AND PHYSICAL Subjective DSM-5 Soc Hx: Alcohol/Tobacco/Drugs Review of Symptoms: Substance (Alcohol) Use Disorder CAGE

22 HISTORY AND PHYSICAL DSM-5 Objective BMI: <19, Russell s Sign Review of Symptoms: Do you make yourself sick because you are uncomfortably full? Do you believe yourself to be fat when others say you are too thin?

23 HISTORY AND PHYSICAL DSM-5 Anorexia Nervosa Bulimia Nervosa Objective BMI: <19, Russell s Sign Review of Symptoms: Do you make yourself sick because you are uncomfortably full? Do you believe yourself to be fat when others say you are too thin?

24 HISTORY AND PHYSICAL DSM-5 Objective A&OX3: Disoriented Review of Symptoms: Repeat: ball/chair/purple Name the recent presidents

25 HISTORY AND PHYSICAL DSM-5 Major/Minor Neurocognitive Disorder Delirium Objective A&OX3: Disoriented Review of Symptoms: Repeat: ball/chair/purple Name the recent presidents

26 DON T MISS HISTORY AND PHYSICAL Subjective CC: Difficulty sleeping/concentrating HPI: Panic attack/sigecaps ROS: SI/HI/AVH Soc Hx: Alcohol/Tobacco/Drugs Objective BMI: <19 A&OX3: Disoriented MSE: appearance, grooming Skin: Evidence of cutting Russell s sign

27 SUMMARY A NEW PSYCHIATRIC SCREENING TOOL FOR THE FAMILY PHYSICIAN Don t Miss History and Physical - Review of Symptoms - Based on DSM-5 27

28 SUMMARY 1998 DSM DSM-5 Why important? 25-30% PCM visits Increased diagnosis and therapy Review of Symptoms Mnemonic Don t Miss H&P Conditions Covered Depression Personality Disorder Substance Abuse Anxiety Somatization Cognitive Disorder Psychotic Disorder All of these + ADHD Adjustment Disorder PTSD Autism Spectrum Disorder (- Somatization) 28

29 ACKNOWLEDGEMENTS THANK YOU: Lindsay H Gleason, Psy.D, ABPP Susan Ebbinghouse, MSIS

30 REFERENCES AMERICAN PSYCHIATRIC ASSOCIATION. (2013). DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (5TH ED.). WASHINGTON, DC. CAPLAN J, STERN T. MNEOMINICS IN A MNUTSHELL: 32 AIDS TO PSYCHIATRIC DIAGNOSIS. CURRENT PSYCHIATRY OCT; 7(10). CARLAT J. THE PSYCHIATRIC REVIEW OF SYMPTOMS: A SCREENING TOOL FOR FAMILY PHYSICIANS. AM FAM PHYSICIAN ;58(7) HARRINGTON B, JIMERSON M. INITIAL EVALUATION, DIAGNOSIS, AND TREATMENT OF ANOREXIA NERVOSA AND BULIMIA NERVOSA. AMERICAN FAMILY PHYSICIAN JAN; 91(1): OLFSON M, KROENKE K, WANG S, BLANCO C. TRENDS IN OFFICE-BASED MENTAL HEALTH CARE PROVIDED BY PSYCHIATRISTS AND PRIMARY CARE PHYSICIANS. J CLIN PSYCHIATRY MAR;75(3): PARIS J. WHY PSYCHIATRISTS ARE RELUCTANT TO DIAGNOSE. PSYCHIATRY (EDGMONT) JAN; 4(1):

31 QUESTIONS?

32 THANK YOU! LT Daniel Kuckel PGY-1 Family Medicine Get connected! 32